Heart Murmurs

Auscultation Rules of Thumb

“All Physicians Take Money” (rule of thumb/mnemonic) 

aortic valve

• upper right sternal border
  • aortic stenosis
  • flow murmur
  • aortic valve sclerosis

left ventricular outflow tract obstruction

·  lateral displacement of maximal impulse

·  S4 gallop

upper left sternal border (ULSB) harsh, crescendo-decrescendo systolic murmur

• hypertrophic obstructive cardiomyopathy

pulmonic valve

• ULSB
  • pulmonic stenosis
  • flow murmur (e.g., ASD)

tricuspid valve

• lower left sternal border (LLSB)
  • pansystolic murmur (tricuspid regurgitation and VSD) 
  • diastolic murmur (tricuspid stenosis and ASD)

mitral valve

• apex  
  • systolic murmur (mitral regurgitation) 
  • diastolic murmur (mitral stenosis) 

Murmur Cheat Sheet	Crescendo/Decrescendo	Holosystolic
Systolic	AS (to neck)MVP (click)HOCM	MR (to axilla)TR (inspiration increases)VSD (harsh)
Diastolic	Aortic regurgitation	MS (opening snap)

• NOTE: See chart below for abbreviations

Murmur Identification

Lesion	Shape	Location Heard	Altered by	Characteristics
Systolic
Aortic stenosis (AS)	Crescendo-decrescendo	Radiates to neck (carotids) and apex	—	“Parvus et tardus” (pulses weak compared to heart sounds) Follows ejection click (due to halting of valve leaflets)
Hypertrophic cardiomyopathy (HOCM)	Crescendo-decrescendo	—	↓ venous return (e.g., Valsalva) – increases murmur	—
Mitral valve prolapse (MVP)	Late crescendo	—	↑ TPR (e.g., squatting, hand grip) – decreases murmur↓ venous return (e.g., Valsalva) – increases murmur	Mid-systolic click (tensing of chordae tendinae)Loudest at S2Later with ↑ afterload (e.g., hand grip).
Mitral regurgitation (MR)	Holosystolic	Radiates to axilla	↑ TPR (e.g., squatting, hand grip)↑ LA return (e.g., expiration)	High-pitched, blowing
Tricuspid regurgitation (TR)	Holosystolic	Radiates to right sternal border	↑ RA return (e.g., inspiration)	High-pitched, blowing
Ventricular septal defect (VSD)	Holosystolic	—	—	Harsh-sounding
Diastolic
Aortic regurgitation (AR)	Early decrescendo	Left sternal border with patient leaning forward	—	High-pitched blowing heard at end of expiration
Mitral stenosis (MS)	Late rumble	Heard in lateral left decubitus position	↑ LA return (e.g., expiration)	Opening snap (tensing of chordae tendinae) in early diastole after A2
Other
Patent ductus arteriosus (PDA)	Continuous	ULSB	—	Machine-like, continuous/constant murmur heard through systole and diastole
Atrial septal defect (ASD)	Systolic and diastolic	Systolic: ULSB (pulmonic valve)Diastolic: LLSB (tricuspid valve)	—	—